YY1 Knockdown Relieves the Differentiation Block and Restores Apoptosis in AML Cells

Simple Summary Acute myeloid leukemia (AML) is characterized by the expansion of clonally derived hematopoietic precursors undergoing a partial or complete maturation block. De novo AML is characterized by recurrent cytogenetic alterations such as chromosomal translocations. However, in the recent past, it was shown that several somatic mutations and epigenetic alterations also contribute to AML onset and progression. Epigenetic mechanisms regulate the equilibrium between self-renewal and differentiation of hematopoietic stem cells and precursors. In this context, Polycomb-group (PcG) proteins regulate the expression of genes involved in cell-cycle regulation and differentiation, and aberrant expression and/or mutations of PcG genes have been shown to occur in hematopoietic neoplasms. Abstract In this study we analyzed the expression of Yin and Yang 1 protein (YY1), a member of the noncanonical PcG complexes, in AML patient samples and AML cell lines and the effect of YY1 downregulation on the AML differentiation block. Our results show that YY1 is significantly overexpressed in AML patient samples and AML cell lines and that YY1 knockdown relieves the differentiation block. YY1 downregulation in two AML cell lines (HL-60 and OCI-AML3) and one AML patient sample restored the expression of members of the CEBP protein family, increased the expression of extrinsic growth factors/receptors and surface antigenic markers, induced morphological cell characteristics typical of myeloid differentiation, and sensitized cells to retinoic acid treatment and to apoptosis. Overall, our data show that YY1 is not a secondary regulator of myeloid differentiation but that, if overexpressed, it can play a predominant role in myeloid differentiation block.


Introduction
Acute myeloid leukemia (AML) is characterized by the expansion of clonally derived hematopoietic precursors undergoing a partial or a complete maturation block. De novo AML is characterized by recurrent cytogenetic alterations, such as chromosomal translocations [1], somatic mutations [2], and epigenetic alterations [3]. Epigenetic drivers of de novo

Ethics Statement
The study was approved by the ethical committee of the University of Rome Tor Vergata (Study Protocol 171/19).

Human Samples and AML Cell Lines
Immature CD34+ and mononuclear CD34− cell fractions were purified from the cord blood of four healthy donors with immunomagnetic column separation (Miltenyi Biotec Inc.; Auburn, CA, USA; and STEMCELL Technologies; Cambridge, MA, USA). Cord blood was provided by the UOS Regional Bank of Cord Blood. Cells were labeled with human anti-CD34-APC (Miltenyi Biotech Inc., Gaithersburg, Maryland, MD, USA) and sorted on the FACS Aria III (Becton Dickinson, BD Biosciences; Franklin Lakes, NJ, USA).
Acute myeloid leukemia (AML) samples (n = 24) were obtained from the peripheral blood or bone marrow of newly diagnosed leukemia patients showing more than 60% leukemic infiltration (see Supplementary Table S1 for sample features).

RNA Isolated and Analysis
Total RNA was isolated from cells with TRIzol (Invitrogen; Thermo Fisher Scientific; Waltham, MA, USA). cDNA was synthesized from total RNA (1 µg) with the High-Capacity RNA-to-cDNA Kit (Applied Biosystems; Thermo Fisher Scientific), and real-time quantitative RT-PCR was performed to determine expression levels for YY1, HOXA2, HOXD13, C/EBPα, C/EBPδ, C/EBPε, CD11b, CD14, GM-CSFr, CSF1, G-CSFr, CSF2, M-CSFr, CSF3, RARα, and GAPDH. The sequences of the primer pairs used are listed in supplementary methods. All reactions were performed in triplicate on total RNA isolated from three independent cell cultures. Real-time PCR was performed with the SYBR Green dye detection method. Ct values obtained for genes in the samples were normalized with Ct values from GAPDH and calculated following the 2 −∆∆CT or 2 −∆CT method, alternatively.

Chromatin Immunoprecipitation (ChIp)
Chromatin immunoprecipitations were performed on lysates prepared from HL-60 cells and using rabbit anti-human YY1 (sc-1703, Santa-Cruz Biotechnology) following a standard protocol. Rabbit anti-human IgG antibodies (Merck Millipore; Burlington, MA, USA) were used as immunoprecipitation controls. Genomic regions in 5 promoter sites, within 1 kb of the putative TSS, of RARα, C/EBPα, C/EBPδ, C/EBPε, and GAPDH genes were amplified from immunoprecipitated DNAs. The sequences of the primer pairs used are listed in supplementary methods. All primer pairs were designed with Primer Express Version 3.0 software (Applied Biosystems; Foster City, CA, USA). qRT-PCR was performed in triplicate with SYBR Green. Values obtained for the DNA in each immunoprecipitated sample were quantified relative to the respective input and calculated following the 2 −∆CT method.

Immunophenotypic Analysis
Immunophenotyping was performed with direct immunofluorescence staining of cells: for the HL-60 cell line, APC-conjugated mouse anti-human CD11b (clone ICRF44) and CD14 (clone M5E2; Becton Dickinson Pharmingen); and for the OCI-AML3 cell line, APC-conjugated mouse anti-human CD11b (clone ICRF44, Beckton Dickinson Pharmingen) and CD14 (clone M5E2, Beckton Dickinson Pharmingen). A minimum of 50,000 events was recorded for each sample on a FACSCantoII flow cytometer (BD Biosciences) for HL-60 and on a CytoFLEX flow cytometer (Beckman Coulter, Brea, CA, USA) for OCI-AML3. Apoptotic cell death in HL60 cells was evaluated with the APC Annexin-V Apoptosis Detection Kit with PI (BioLegend, San Diego, CA, USA) according to the manufacturer's instructions on a FACSCantoII flow cytometer (BD Biosciences, Franklin Lakes, NJ, USA), and in OCI-AML3 cells, with Annexin V staining and the 'Live/Dead' assay on a CytoFLEX flow cytometer (Beckman Coulter; Brea, CA, USA). Flow cytometric analysis was performed with FlowJo Flow Cytometric Analysis software (TreeStar; Ashland, OR, USA). Cells labeled with a single fluorochrome were used as controls to adjust the compensation.

Morphological Analysis
HL-60 and OCI-AML3 cell morphology was evaluated using staining cytospin (8 min at 900 rpm) with Wright-Giemsa stains, according to the manufacturer's instructions. Images were captured with a Nikon Eclipse 80i upright microscope.

Statistical Analysis
All data are expressed as mean ± DS, and the ± DS are represented by error bars. The statistical significance was calculated with a one-tailed Mann-Whitney non-parametric test with GraphPad Prism 5, and a p-value ≤ 0.05 was considered as significant. The experiments were performed at least three times in duplicate unless otherwise stated.

An Inhibitor of NF-kB Activation, Bortezomib, Downregulates YY1 in AML Cells
The proteasome inhibitor Bortezomib, approved by the FDA for clinical use in multiple myeloma and in AML clinical trials [91,92], has been shown to inhibit NF-kB activation [93]. About 40% of AML patients exhibit increased activity of the NF-kB signaling pathway, and it is constitutively active in CD34+/CD38-blasts from M1, M2, M4, and M5 AML patients [94,95]. YY1 is a target of NF-kB activation [96,97]. Therefore, to further elucidate the role of YY1 in hematopoietic differentiation and the development of AML, we investigated whether Bortezomib decreased the expression of YY1 in AML cells. We first analyzed YY1 expression in 24 AML samples (Supplementary Table S1) and 5 AML cell lines (HL-60, AML-193, ML-2, ME-1, and OCI-AML3) [88,89]. qRT-PCR analysis revealed a statistically significant increase in YY1 mRNA levels in the AML patient samples and AML cell lines compared with four immature CD34+ cells and four CD34-mononuclear mature cell samples purified from umbilical cord blood of four healthy donors ( Figure 1A). Next, we treated cells from a YY1 high-expressing AML sample ( Figure 1B) with 2.5 nM Bortezomib and analyzed YY1 mRNA and protein levels over 72 h at 24 h intervals ( Figure 1C). Bortezomib significantly reduced YY1 expression as early as 24 h. However, co-treatment with the vitamin ATRA (1 µM) did not lead to a further decrease in YY1 in Bortezomib+ATRAtreated AML cells ( Figure 1C). Indeed, Bortezomib treatment led to an increase in the mRNA and protein levels of transcription factors C/EBPε and C/EBPδ (CCAAT/enhancer binding protein ε, δ) ( Figure 1D), which are directly involved in granulocytic terminal differentiation, whereas no difference in C/EBPα expression was observed.
Remarkably, Bortezomib caused an increase in the expression of the granulocytic surface antigen differentiation marker CD11b, whereas no change in expression was observed for the monocytic surface antigen CD14 ( Figure 1E).

YY1 Knockdown Induces Expression of Myeloid Differentiation Markers
Based on these results and data in the literature [86][87][88][89], we investigated the possibility that YY1 overexpression could interfere with the myeloid differentiation program in AML cell lines. YY1 protein levels were downregulated in the HL-60 cell line (FAB M2) with a doxycycline inducible lentiviral vector expressing a short hairpin against YY1 mRNA, and in the OCI-AML3 (FAB M4) cell line, with the transfection of a small-interfering RNA targeting YY1. Both knockdown approaches caused a significant reduction in YY1 protein in these cell lines, at 120 h of doxycycline induction (300 ng/mL) in HL-60-sh-YY1-doxy and at 48 h and 96 h in OCI-AML3-siYY1 (Figure 2A,B). Furthermore, the mRNA expression of HOXA2 and HOXD13 genes increased in response to YY1 knockdown, demonstrating that knockdown of YY1 in these cells led to a previously characterized functional response of the downregulation of YY1 protein [96] (Figure 2C,D).  interfering RNA targeting YY1. Both knockdown approaches caused a significant reduction in YY1 protein in these cell lines, at 120 h of doxycycline induction (300 ng/mL) in HL-60-sh-YY1-doxy and at 48 h and 96 h in OCI-AML3-siYY1 (Figure 2A,B). Furthermore, the mRNA expression of HOXA2 and HOXD13 genes increased in response to YY1 knockdown, demonstrating that knockdown of YY1 in these cells led to a previously characterized functional response of the downregulation of YY1 protein [96] ( Figure 2C,D).  We next investigated the effect of YY1 knockdown on C/EBP family members α, ε, and δ, which have an important role in normal hematopoiesis, mainly in the promotion of myeloid differentiation, and which are decreased in expression or frequently mutated in AML [98][99][100][101]. Knockdown of YY1 in the HL-60-sh-YY1-doxy and OCI-AML3-siYY1 cell lines caused a statistically significant increase in C/EBPε and C/EBPδ expression, both at the transcriptional and protein levels compared with control cells ( Figure 3A,B).

YY1 Knockdown Increases Expression of C/EBP Family Proteins and Myeloid Growth Factors/Receptors in ATRA-Treated HL-60 and OCI-AML3 Cell Lines
The knockdown of YY1 protein in the AML patient sample and in the HL-60 and OCI-AML3 cell lines led to an increase in the expression of genes associated with myeloid differentiation, including myeloid transcription factors (C/EBPε, C/EBPδ), myeloid growth factors receptors (GM-CSFr, G-CSFr), and the granulocytic differentiation marker (CD11b).
The HL-60 cell line is a model for granulocytic differentiation when treated with ATRA [102], although this cell line does not carry the PML/RARα translocation. The OCI-AML3 cell line carries the nucleophosmin gene mutation (NPM1mut), which is found in approximately 30% of adult leukemia cases [103]. Treatment of NPM1mut AMLs with ATRA, or in combination with ATO or chemotherapy, has been shown to increase apoptosis and improve the outcomes of elderly patients [104][105][106]. Therefore, we asked if knockdown of YY1 increased the sensitivity of the HL-60 and OCI-AML3 cell lines to ATRA treatment. HL-60sh and -sh-doxy, -sh-YY1-doxy following doxycycline induction, and OCI-AML3 siSC-CT and -siYY1 after transfection were collected during treatment with 1 µM ATRA over 96 h at 24 h intervals. YY1 protein levels were efficiently downregulated throughout the ATRA exposure time in HL-60-sh-YY1-doxy relative to control cells ( Figure 4A). Exposure to 1 µM ATRA led to a statistically significant increase in expression of C/EBPα, C/EBPε, and C/EBPδ in HL-60-sh-YY1-doxy relative to the control HL-60-sh-doxy at all time points ( Figure 4B-D). However, C/EBPα showed increased expression as early as 2.5 h after exposure to ATRA, also confirmed with Western blot ( Figure 4B), while C/EBPδ did not show an increase until the 24 h time point for ATRA exposure ( Figure 4D). We next investigated the effect of YY1 knockdown on C/EBP family members α, ε, and δ, which have an important role in normal hematopoiesis, mainly in the promotion of myeloid differentiation, and which are decreased in expression or frequently mutated in AML [98][99][100][101]. Knockdown of YY1 in the HL-60-sh-YY1-doxy and OCI-AML3-siYY1 cell lines caused a statistically significant increase in C/EBPε and C/EBPδ expression, both at the transcriptional and protein levels compared with control cells (Figure 3A,B). Finally, we assessed the expression levels of growth factors involved in myeloid differentiation, including colony-stimulating factor 2 (CSF2), 3 (CSF3), and 1 (CSF1), and the receptors they bind to, granulocyte-macrophage-colony-stimulating factor receptor (GM-CSFr), granulocyte-colony-stimulating factor receptor (G-CSFr), and macrophagecolony-stimulating factor receptor (M-CSFr). We found that while the levels in growth factors did not change, GM-CSFr was significantly upregulated in both HL-60-sh-YY1doxy and OCI-AML3-siYY1, while G-CSFr was significantly upregulated only in HL-60sh-YY1-doxy (Supplementary Figure S1).

YY1 Knockdown Increases Expression of C/EBP Family Proteins and Myeloid Growth Factors/Receptors in ATRA-Treated HL-60 and OCI-AML3 Cell Lines
The knockdown of YY1 protein in the AML patient sample and in the HL-60 and OCI-AML3 cell lines led to an increase in the expression of genes associated with myeloid differentiation, including myeloid transcription factors (C/EBPε, C/EBPδ), myeloid growth factors receptors (GM-CSFr, G-CSFr), and the granulocytic differentiation marker (CD11b). The HL-60 cell line is a model for granulocytic differentiation when treated with Expression of the RARα cytoplasmic ATRA receptor was also increased in HL-60-sh-YY1-doxy, and this increase was enhanced several fold with ATRA treatment ( Figure 4E). In addition, CSF1, CSF3, GMCSF-r, GCSF-r, and MCSF-r were statistically increased in ATRA-treated HL-60-sh-YY1-doxy relative to ATRA-treated HL-60-sh-doxy and untreated HL-60-sh-YY1-doxy (Supplementary Figure S2). Expression of C/EBPα, C/EBPε, and C/EBPδ was also increased in ATRA-treated OCI-AML3-siYY1 relative to ATRA-treated OCI-AML3-siSc-CT. YY1 protein levels were efficiently downregulated throughout the ATRA exposure time also in OCI-AML3-siYY1 ( Figure 5A); however, this increase was not significantly greater than the expression of these genes in untreated OCI-AML3-siYY1 ( Figure 5B). with 1 μM ATRA over 96 h at 24 h intervals. YY1 protein levels were efficiently downregulated throughout the ATRA exposure time in HL-60-sh-YY1-doxy relative to control cells ( Figure 4A). Exposure to 1 μM ATRA led to a statistically significant increase in expression of C/EBPα, C/EBPε, and C/EBPδ in HL-60-sh-YY1-doxy relative to the control HL-60-sh-doxy at all time points (Figure 4B-D). However, C/EBPα showed increased expression as early as 2.5 h after exposure to ATRA, also confirmed with Western blot (Figure 4B), while C/EBPδ did not show an increase until the 24 h time point for ATRA exposure ( Figure 4D). Expression of the RARα cytoplasmic ATRA receptor was also increased in HL-60-sh-YY1-doxy, and this increase was enhanced several fold with ATRA treatment ( Figure 4E). In addition, CSF1, CSF3, GMCSF-r, GCSF-r, and MCSF-r were statistically increased in ATRA-treated HL-60-sh-YY1-doxy relative to ATRA-treated HL-60-sh-doxy and untreated HL-60-sh-YY1-doxy (Supplementary Figure S2). Expression of C/EBPα, C/EBPε, and C/EBPδ was also increased in ATRA-treated OCI-AML3-siYY1 relative to ATRA-treated OCI-AML3-siSc-CT. YY1 protein levels were efficiently downregulated throughout the ATRA exposure time also in OCI-AML3-siYY1 ( Figure 5A); however, this increase was not significantly greater than the expression of these genes in untreated OCI-AML3-siYY1 ( Figure 5B).

YY1 binds C/EBPα, C/EBPε, C/EBPδ, and RARα Gene Promoters
Knockdown of YY1 determined an increased expression in some C/EBP protein family members in both cell lines and RARα in HL-60 cells. In these cells, YY1 could act as a transcriptional repressor protein of these genes, and loss of the protein may relieve the promoter regions of the C/EBPs and RARα genes of YY1 transcriptional repression.

YY1 binds C/EBPα, C/EBPε, C/EBPδ, and RARα Gene Promoters
Knockdown of YY1 determined an increased expression in some C/EBP protein family members in both cell lines and RARα in HL-60 cells. In these cells, YY1 could act as a transcriptional repressor protein of these genes, and loss of the protein may relieve the promoter regions of the C/EBPs and RARα genes of YY1 transcriptional repression. The Jaspar core 2022 database (consultable on the UCSC genome browser) predicted the presence of putative YY1 binding sites in the 5 promoter regions of C/EBPα, C/EBPε, C/EBPδ, and RARα. Therefore, we performed chromatin immunoprecipitation (ChIp) with lysates prepared from HL-60-sh-YY1-doxy and -sh-doxy cells to determine YY1 occupancy of the 5 promoter regions of the C/EBP and RARα genes. Immunoprecipitations were performed on lysates prepared from HL-60-sh-YY1-doxy and -sh-doxy cells induced with doxycycline for 96 h and treated or untreated with ATRA for an additional 96 h. ChIp data showed reduced binding of the 5 promoter regions of C/EBPα, C/EBPε, C/EBPδ, and RARα in the HL-60-sh-YY1-doxy cells, thus demonstrating that YY1 bound to these putative sites ( Figure 6). Consequently, the increased expression of these genes in HL-60 (sh-YY1-doxy) relative to HL-60 (sh-doxy) cells might be due to reduced binding of YY1 to their promoter regions, and thus, the loss of its repressive effect on the transcription of these genes. In the case of C/EBPα, ChIp data confirmed reduced YY1 binding at the 5 promoter region in sh-YY1-doxy cells; however, this was not accompanied by an increase in the C/EBPα expression, apparently in contradiction with the increased expression observed when the same cells were exposed to ATRA ( Figure 4B). A possible explanation might be that the C/EBPα promoter, following YY1 displacement, will became available to the binding of an ATRA-induced transcription factor.

YY1 Knockdown Enhances Expression of Myeloid Differentiation Markers and Cell Morphological Differentiation Features
To investigate the relationship between YY1 knockdown and myeloid differentiation, we monitored the expression of surface adhesion molecules, granulocytic CD11b and monocytic CD14 [107], and changes in the cell morphology of HL-60-sh-YY1-doxy andsh-doxy and OCI-AML3-siYY1 and -siSC-CT cells, treated or untreated with 1 μM ATRA.
We also assessed CD11b and CD14 expression with qRT-PCR. CD11b was significantly higher in ATRA-untreated HL-60-sh-YY1-doxy cells than in ATRA-untreated HL-60-shdoxy cells ( Figure 8A; CD11b data are graphed separately, as the relative increase in CD11b mRNA in ATRA-treated samples was so much higher than in untreated cells), although no significant increase in CD11b was observed on flow cytometry for the same time points.
The exposure to ATRA potently induced CD11b in HL-60-sh-doxy, as expected, and the YY1 knockdown enhanced this effect ( Figure 8B). CD14 appeared to be significantly increased in the ATRA-untreated HL-60-sh-YY1-doxy cells at 96 h, despite negative flow cytometry, and in the ATRA-treated HL-60-sh-YY1-doxy cells at all time points, compared with the control HL-60-sh-doxy cells. Thus, YY1 knockdown also enhanced CD14 expression in ATRA-treated cells ( Figure 8C). The exposure to ATRA potently induced CD11b in HL-60-sh-doxy, as expected, and the YY1 knockdown enhanced this effect ( Figure 8B). CD14 appeared to be significantly increased in the ATRA-untreated HL-60-sh-YY1-doxy cells at 96 h, despite negative flow cytometry, and in the ATRA-treated HL-60-sh-YY1-doxy cells at all time points, compared with the control HL-60-sh-doxy cells. Thus, YY1 knockdown also enhanced CD14 expression in ATRA-treated cells ( Figure 8C).
Finally, cell morphology as assessed with Wright-Giemsa staining and quantitation of the different cell types, showed that in both HL-60 and OCI-AML3, YY1 knockdown was sufficient to induce chromatin condensation with nuclear segmentation, increased granulation, and reduced cytosolic basophilia ( Figure 9A,B). In addition, YY1 knockdown enhanced the pro-differentiation effect of ATRA in both HL-60 and OCI-AML3 cell lines, with a surprising effect in HL-60 cells at 96 h ( Figure 9A-C). Finally, cell morphology as assessed with Wright-Giemsa staining and quantitation of the different cell types, showed that in both HL-60 and OCI-AML3, YY1 knockdown was sufficient to induce chromatin condensation with nuclear segmentation, increased granulation, and reduced cytosolic basophilia ( Figure 9A,B). In addition, YY1 knockdown enhanced the pro-differentiation effect of ATRA in both HL-60 and OCI-AML3 cell lines, with a surprising effect in HL-60 cells at 96 h ( Figure 9A-C). The exposure to ATRA potently induced CD11b in HL-60-sh-doxy, as expected, and the YY1 knockdown enhanced this effect ( Figure 8B). CD14 appeared to be significantly increased in the ATRA-untreated HL-60-sh-YY1-doxy cells at 96 h, despite negative flow cytometry, and in the ATRA-treated HL-60-sh-YY1-doxy cells at all time points, compared with the control HL-60-sh-doxy cells. Thus, YY1 knockdown also enhanced CD14 expression in ATRA-treated cells ( Figure 8C).
Finally, cell morphology as assessed with Wright-Giemsa staining and quantitation of the different cell types, showed that in both HL-60 and OCI-AML3, YY1 knockdown was sufficient to induce chromatin condensation with nuclear segmentation, increased granulation, and reduced cytosolic basophilia ( Figure 9A,B). In addition, YY1 knockdown enhanced the pro-differentiation effect of ATRA in both HL-60 and OCI-AML3 cell lines, with a surprising effect in HL-60 cells at 96 h ( Figure 9A-C). Collectively, these data demonstrate that YY1 knockdown overcame the differentiation block, driving HL-60 and OCI-AML3 cells towards granulo/mono cell differentiation. In addition, the YY1 knockdown cells seemed more sensitive to ATRA treatment. Overall, these data demonstrate that YY1 downregulation is not only essential for differentiation but also sensitizes AML cells to the therapeutic effect of ATRA.
Collectively, these data demonstrate that YY1 knockdown overcame the differentiation block, driving HL-60 and OCI-AML3 cells towards granulo/mono cell differentiation. In addition, the YY1 knockdown cells seemed more sensitive to ATRA treatment. Overall, these data demonstrate that YY1 downregulation is not only essential for differentiation but also sensitizes AML cells to the therapeutic effect of ATRA.
In conclusion, these data suggest that YY1 downregulation might not only stimulate commitment in HL-60 and OCI-AML3 cells, but also promote apoptosis in these cells.

Discussion
The role of the YY1 protein in carcinogenesis and the progression of solid tumors is well established [76][77][78][79][80][81][82][83][84][85], as well as in lymphoid leukemia [109][110][111][112]. Although YY1 is generally overexpressed in AML [88,89], it is not known if YY1 overexpression may, per se, induce leukemic transformation. In addition, data from the cancer genome atlas (TCGA) database (https://servers.binf.ku.dk/bloodspot/, accessed on 1 July 2023) highlighted a heterogenous YY1 expression among AML samples, without the presence of associations with specific mutational features and patient prognosis (Supplementary Figure S4). However, to date, no molecular studies have been conducted to determine the mechanisms by which YY1 may interfere with normal myelopoiesis, and above all, no data are available on the effect of YY1 downregulation in human AML cells. In this study, we knocked down YY1 in human AML cells, primarily through RNA interference strategies, to investigate the role of YY1 in myeloid differentiation and AML. YY1 knockdown in an AML sample and AML cell lines restored/increased mRNA and protein PARP1 activation and caspase 3 showed the same trend on Western blots. PARP1 and caspase 3 cleaved forms were more abundant in ATRA-untreated and -treated OCI-AML3-siYY1 cells compared with control OCI-AML3-siSC-CT cells ( Figure 11B).
In conclusion, these data suggest that YY1 downregulation might not only stimulate commitment in HL-60 and OCI-AML3 cells, but also promote apoptosis in these cells.

Discussion
The role of the YY1 protein in carcinogenesis and the progression of solid tumors is well established [76][77][78][79][80][81][82][83][84][85], as well as in lymphoid leukemia [109][110][111][112]. Although YY1 is generally overexpressed in AML [88,89], it is not known if YY1 overexpression may, per se, induce leukemic transformation. In addition, data from the cancer genome atlas (TCGA) database (https://servers.binf.ku.dk/bloodspot/, accessed on 1 July 2023) highlighted a heterogenous YY1 expression among AML samples, without the presence of associations with specific mutational features and patient prognosis (Supplementary Figure S4). However, to date, no molecular studies have been conducted to determine the mechanisms by which YY1 may interfere with normal myelopoiesis, and above all, no data are available on the effect of YY1 downregulation in human AML cells. In this study, we knocked down YY1 in human AML cells, primarily through RNA interference strategies, to investigate the role of YY1 in myeloid differentiation and AML. YY1 knockdown in an AML sample and AML cell lines restored/increased mRNA and protein expression of C/EBP family members, including C/EBPα, C/EBPε, and C/EBPδ, involved in normal and leukemic myelopoiesis [113], and promoted the expression of pro-myeloid growth factor receptors such as GM-CSFr and G-CSFr in HL-60 and of GM-CSFr in OCI-AML3. YY1 knockdown also increased the sensitivity of an AML patient sample and the AML cell lines to ATRA treatment, a standard-of-care therapy used in the clinic. ChIp experiments revealed that YY1 occupied C/EBPα, C/EBPε, and C/EBPδ 5 promoter regions in the AML cell lines, thus functioning in this context as a suppressor of transcription. Finally, we showed that YY1 is able to bind the RARα promoter region, the ATRA receptor, and that the loss of YY1 increased the expression of RARα per se. Thus, an explanation for the increased sensitivity of AML cells with YY1 knockdown to ATRA may be related to the removal of the repressive effect on RARα transcription and to the increased availability of the ATRA receptor [114].
Remarkably, YY1 knockdown not only induced the expression of C/EBPα, C/EBPε, C/EBPδ, and RARα but also relieved the differentiation block in AML cells. In HL-60 cells, YY1 downregulation generated cell populations that showed robust expression of CD11b but nearly negative CD14 staining. ATRA exposure boosted the expression of CD11b and a significant increase in CD14. In OCI-AML3, YY1 downregulation produced the same results, even if quantitatively less important. This result is probably related to the fact that the cell lines are at a different stage of differentiation block (OCI-AML3 is a FAB M4 acute myelomonocytic leukemia, and HL-60 is a FAB M2 acute myeloblastic leukemia with maturation). These data were supported by the morphological analyses. YY1 knockdown in HL-60 and OCI-AML3 cells clearly showed a recovery of commitment toward mature myeloid lineages, and this direction towards differentiation was even more evident when cells were exposed to ATRA. In particular, ATRA-treated HL-60-sh-YY1-doxy cells appeared to achieve a high degree of granulocytic differentiation. Our data paralleled the morphologic studies conducted by Erkeland et al. [89], showing an impairment of myeloid commitment when YY1 was ectopically expressed in a murine hematopoietic progenitor cell line model.
Evasion from apoptosis is a hallmark of malignant tumor progression, and identifying strategies to induce or restore defective apoptosis is a major priority in the development of cancer therapy. The development of AML has also been shown to be dependent on dysregulation of the apoptotic pathway. For instance, the overexpression of BCL2, which is an important antiapoptotic protein in AML, led to the development of BCL2 inhibitors to promote the induction of apoptosis in AML cells and has led to the discovery of venetoclax, a potent and selective BCL2 inhibitor [115]. More than 250 scientific articles (PubMed) show a direct role for the deregulated expression of YY1 in inhibiting apoptotic pathways through a variety of mechanisms. For the first time, our data show that the reduction in YY1 expression in HL-60 and OCI-AML3 cell lines restored apoptosis as shown by the activation of PARP1 and caspase 3 and the increased expression of the pro-apoptotic protein BAX.

Conclusions
Collectively, our data propose a central role for YY1 in the development of AML. YY1 downregulation restored the expression of myeloid C/EBP transcription factors and growth factors; increased the availability of RARα, making cells more sensitive to ATRA exposure; and restored apoptosis in AML cell lines. Therefore, YY1 represents a novel target of investigation in the quest to improve AML patient treatment [39].
Supplementary Materials: The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/cancers15154010/s1, File S1: The original western blot figures; Figure S1: mRNA expression of myeloid growth factors and receptors in HL-60 and OCI-AML3 YY1 interfered cell lines. mRNA expression levels were normalized to GAPDH levels and expressed as fold induction to control cells value (=1). Each qRT-PCR amplification was performed in triplicate. Statistical analysis was performed in triplicate using the nonparametric Mann-Whitney test. * p value ≤ 0.05. Error bars: SD, standard deviation; Figure S2: mRNA expression of myeloid growth factors and receptors in HL-60 control sh-doxy and YY1 interfered sh-yy1-doxy cell lines. mRNA expression levels were normalized to GAPDH levels and expressed as fold induction to control cells value (=1). Each qRT-PCR amplification was performed in triplicate. Statistical analysis was performed in triplicate using the nonparametric Mann-Whitney test. * p value ≤ 0.05. Error bars: SD, standard deviation; Figure S3: Cell proliferation of YY1 knocked down HL-60 (sh-yy1 doxy) and OCI-AML3 (siyy1) cells vs. their respective cell controls HL-60 sh-doxy and OCI-AML3 siSC-CT, at the indicated time points. * p value ≤ 0.05; Figure S4: data from the cancer genome atlas (TCGA) database (https://servers.binf.ku.dk/bloodspot/) highlighted a heterogenous YY1 expression among AML samples, without the presence of associations with specific mutational features and patient prognosis; Table S1: AML patient sample characteristics.